Transcript Chapter 20

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.
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Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.
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History and Physical (H&P)
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Date
Demographic data
Source of referral
Chief complaint(s)
History of present illness
Past history
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History and Physical (H&P)
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Current health status
Family history of illness
Psychosocial history
Review of all systems
Information is called baseline
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Variances from Normal
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Discriminate normal from abnormal
Observation skills
Use of questions
Note changes in condition
Need strong assessment skills
Report variances to supervisor
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General Survey
• Look at patient as whole
• Overall impression is valuable information
• Determines where to focus if time is
limited
• What to look for in a general survey
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Psychosocial Assessment
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Part of the general survey
Emotional status
Mental status
Appearance
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Physical Assessment Skills
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Inspection
Auscultation
Palpation
Percussion
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Assess Systems
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Musculoskeletal
Integumentary
Circulatory
Respiratory
Digestive
Urinary
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Assess Systems
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Eyes
Ears
Nervous
Endocrine
Female reproductive
Male reproductive
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Pain Assessment
• Subjective information
• Use pain assessment scale
• Scale is 0-10, 0 is no pain, 10 is worst
imaginable
• Compare levels before and after pain
medications
• Note nonverbal cues
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ADL Assessment
• Activities of daily living (ADL)
• Actions done on a regular basis to meet
physical needs
• Inability to perform ADLs
– Assistance needed as long as unable to do so
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Vital Signs (VS)
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Temperature
Pulse
Respiratory
Blood pressure
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Temperature
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Normal range essential to homeostasis
Afebrile and febrile
Intermittent fever
Continuous fever
Night sweats
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Thermometer Routes
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Oral
Axillary
Rectal
Aural
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Pulse
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Pulse points
Regular rhythm
Irregular rhythm
Regular irregular rhythm
Irregular irregular rhythm
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Pulse
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Apical pulse
Stethoscope
Bradycardia
Tachycardia
Pulse deficit
Apical-radial pulse deficit
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Respiration
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Process of moving air through lungs
Inhalation (inspiration)
Exhalation (expiration)
Eupnea
Tachypnea
Bradypnea
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Respiration
• Make sure patient is unaware respirations
are being counted
• Rate
• Rhythm
– Apnea
– Cheyne-Stokes
• Respiratory effort
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Blood Pressure (BP)
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Systolic
Diastolic
Hypotension
Hypertension
Sphygmomanometer
Orthostatic (postural) hypotension
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Height and Weight
• Height usually stable after adulthood,
except with osteoporosis
• Many factors affect weight
• Standing balance scale
• Chair and wheelchair scales
• Mechanical lift scales
• Bed scales
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